CanJPsychiatry 2015;60(3):146–150
Original Research
Association Between Mental Health Apprehensions by Police and Monthly Income Assistance (Welfare) Payments Tracy A Pickett, MD, BSc (MForensMed Candidate), FRCPC1; Robert J Stenstrom, MD, PhD, CCFP(EM)2; Riyad B Abu-Laban, MD, MHSc, DABEM, FRCPC3 Attending Physician, Emergency Department, St Paul’s Hospital, Vancouver, British Columbia; Clinical Associate Professor, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia; Graduate Student, Department of Forensic Medicine, Monash University, Melbourne, Australia. Correspondence: Emergency Department, St Paul’s Hospital, 1081 Burrard Street, Vancouver, BC V6Z 1Y6; [email protected].
1
Attending Physician and Research Director, Emergency Department, St Paul’s Hospital, Vancouver, British Columbia; Assistant Professor, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia.
2
3
Attending Physician, Emergency Department, Vancouver General Hospital, Vancouver, British Columbia; Associate Professor and Research Director, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia.
Key Words: mental health apprehension, police, welfare, income assistance payment, emergency department, temporal trends, time series Received March 2014, revised, and accepted September 2014. This study was presented in abstract form in an oral presentation at the Canadian Association of Emergency Physicians Conference, Ottawa, Ontario, June 1, 2014.
Objective: Social misconduct, increased police activity, and increased emergency department (ED) use are associated with monthly income assistance (welfare) payments. The relation, if any, between welfare payments and mental health and addictions presentations to the ED requiring police involvement remains unknown. Our purpose was to determine if a relation exists between mental health apprehensions (MHAs) by police and monthly welfare cheque distribution, and the association between monthly payments and mental health and substance-related ED presentations. Method: The Vancouver Police administrative database was analyzed during an 81-week period (June 8, 2011, to December 25, 2012). Comparisons were made between the numbers of MHAs by police during the week following welfare payment to those during nonpayment weeks. The weekly number of mental health and substance-related ED presentations were also analyzed during the study period. MHAs were analyzed continuously, and compared using the 2-tailed t test. Results: During the study period, 4009 MHAs occurred (range 1 to 18 MHAs/day). The mean weekly MHAs during welfare week was 54.6 (95% CI 51.75 to 57.45), compared with 48.6 (95% CI 46.35 to 50.85) during nonpayment weeks (P = 0.004). This translates to 85 MHAs annually related to welfare payments. Total mental health and addictions-related presentations to the ED were also significantly increased in the week following welfare payments (P < 0.001), and could not be solely attributed to increased MHAs by police. Conclusion: A statistically significant increase in the number of MHAs by police follows welfare payments. This is superimposed on a significant increase in overall mental health and substance-related ED presentations seen during the same period. WWW
Association entre les arrestations pour santé mentale faites par la police et le revenu mensuel des prestations d’aide sociale (bien-être) Objectif : L’inconduite sociale, l’intervention accrue de la police, et l’utilisation en hausse des services d’urgence (SU) sont associées au revenu mensuel des prestations d’aide sociale (bien-être). La relation, si elle existe, entre les prestations d’aide sociale, la santé mentale, et les visites au SU pour toxicomanies qui demandent l’intervention de la police demeure inconnue. Notre objectif était de déterminer s’il existe une relation entre les arrestations pour santé mentale (ASM) faites par la police et la distribution mensuelle des chèques de bien-être, et l’association entre les prestations mensuelles et la santé mentale et les visites au SU liées à des substances. Méthode : La base de données administrative de la police de Vancouver a été analysée durant 81 semaines (du 8 juin 2011 au 25 décembre 2012). Des comparaisons ont été établies entre le nombre d’ASM faites par la police durant la semaine suivant les prestations d’aide sociale et celles faites durant les semaines sans prestations. Le nombre hebdomadaire de visites au SU liées à la santé mentale et aux substances a aussi été analysé durant la période de l’étude. Les ASM ont été analysées en continu, et comparées à l’aide du test t bilatéral. 146 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
www.LaRCP.ca
Association Between Mental Health Apprehensions by Police and Monthly Income Assistance (Welfare) Payments
Résultats : Durant la période de l’étude, il y a eu 4009 ASM (de 1 à 18 ASM par jour). La moyenne hebdomadaire des ASM durant la semaine des prestations d’aide sociale était de 54,6 (IC à 95 % 51,75 à 57,45), comparativement à 48,6 (IC à 95 % 46,35 à 50,85) durant les semaines sans prestations (P = 0,004). Ce qui signifie que 85 ASM sont reliées annuellement aux prestations d’aide sociale. Le total des visites au SU liées à la santé mentale et aux toxicomanies augmentait aussi significativement dans la semaine suivant les prestations d’aide sociale (P < 0,001), et ne pouvait pas être attribué uniquement à l’augmentation des ASM faites par la police. Conclusion : Une augmentation statistiquement significative du nombre d’ASM faites par la police suit les prestations d’aide sociale. Elle se superpose à une augmentation significative des visites au SU liées à la santé mentale et aux substances durant la même période.
I
ncome assistance, also known as welfare, is a financial safety net that exists in Canada for eligible people who have limited ability to earn income because of personal circumstances or disability, including mental health issues. Income assistance provides regular payments based on financial need, released once monthly in most provinces as per a predetermined, provincially administered schedule. Monthly lump-sum welfare payments have been associated with increased morbidity, mortality, and crime in both Canada and the United States.1–8 During the past decade, ED overcrowding, deinstitutionalization of mental health patients, and increasingly easy access to drugs of abuse have stretched health care and community resources such that police must increasingly function as de facto front-line mental health workers.9,10 The questions of whether monthly welfare cheque distribution affects police interactions with mental health patients, and any impact this has on ED activity, has previously not been addressed. In Vancouver, about one-third of all calls to police are related to mental health issues.11 Six to 8 per cent of these calls result in apprehension of an individual by Police under Section 28 of the British Columbia Mental Health Act; a legislation that authorizes police to apprehend and transport an individual to a physician for assessment (usually in the ED) if that person appears to have a mental disorder and is acting in a manner with the potential to endanger their safety or the safety of others. Common reasons for apprehension under Section 28 include psychosis, suicidal attempt or ideation, intoxication with drugs or alcohol, and behavioural issues. A Section 28 MHA is often a last resort when police have exhausted other means of resolving a situation. The impact of monthly income assistance payments on the number of MHAs by police has not been studied in Canada or elsewhere. Our objective was to determine if a relation exists between the number of MHAs by police in Vancouver and monthly welfare cheque distribution. We hypothesized that
Clinical Implications •
Predictable and consistent increases in MHAs by police and mental health and substance-related presentations to the ED following monthly welfare payments should be considered in ED staffing, police distribution models, and community resource planning.
•
Changing the model of monthly welfare payments (for example, to a weekly system) could have a smoothing effect on MHAs in the course of each month, and this possibility merits policy consideration and future investigation.
Limitations •
Vancouver is a busy urban centre, with some core regions of the city having a high concentration of inhabitants with mental illness and addictions. Our findings may not be generalizable to other regions.
•
The impact of MHAs were not correlated to ED or police workload or flow.
•
The increase in MHAs following income assistance payments may be related to other unknown and undetermined confounders. It is difficult to assess whether a sociological activity, such as welfare cheque distribution, is causally related to increased police or ED activity, or simply an association in an already marginalized population.
there would be more MHAs in the days on or immediately following welfare cheque payments. Additionally, for secondary purposes, we assessed the number of overall mental health and substance-related presentations to the ED during the study period. We hypothesized that there would also be increased mental health and substance-related ED presentations in the week following welfare payments, but this would not be fully accounted for by increased MHAs by police. If such an association exists, our findings could potentially influence ED and (or) police staffing models, ED surge capacity planning, community resources, and even public and social policies regarding payment approaches.
Methods Abbreviations ED
emergency department
MHA
mental health apprehension
PRIME
Police Records Information Management Environment
www.TheCJP.ca
Study Design and Population
The study took place in Vancouver, a Canadian urban centre with a population of about 800 000 people. We undertook an administrative database investigation of MHAs by the Vancouver Police Department during an The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 147
Figure Weekly (Wednesday to Tuesday) total Mental Health Apprehensions (MHAs) by Vancouver police Original1 Research Figure 1 Weekly (Wednesday to Tuesday) total mental health apprehensions (MHAs) by Vancouver police
80 70 60
Total MHAs, n
50 40 30 20 10 0
Week of study
Welfare payment weeks
Nonwelfare payment weeks
Welfare payment weeks
81-week (567-day) period between June 8, 2011, and Non-welfare payment weeks December 25, 2012. The Vancouver Police Department is a municipal police force with jurisdiction over the City of Vancouver, excluding the University of British Columbia and University Endowment Lands. The study population consisted of all people apprehended by Vancouver Police under Section 28 of the British Columbia Mental Health Act during the study period, as captured through the Vancouver Police Department PRIME database. PRIME is a real-time computer database that records all Vancouver Police Department dispatches and encounters. Variables captured included absolute number of people formally apprehended under Section 28 of the British Columbia Mental Health Act and the date of apprehension. Personal identifiers including name, age, sex, circumstances surrounding the apprehension, prior MHAs, medical diagnosis, or whether an individual received income assistance payments were not collected. People with a police encounter who were otherwise managed without apprehension under Section 28 of the British Columbia Mental Health Act were excluded. The overall number of mental health and substance-related presentations (including police MHAs) to the 2 study hospitals was extracted from the Vancouver Coastal Health Authority regional ED dataset, which holds comprehensive data on all ED encounters at the study hospitals. Data linkage to establish whether patients were receiving welfare payments was not performed.
Sample Size and Selection
We assumed that the number of MHAs per day would be normally distributed. We categorized the daily numbers of MHAs by police into the 1-week (7-day) period following welfare payment (welfare cheque days) or nonpayment weeks (nonwelfare cheque days). Based on about a 3-to-1 ratio of nonwelfare cheque days to welfare cheque days, we 148 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
determined that 510 days (total) were required to have 90% power to detect a 1-call per day mean difference (standard deviation of 3 calls per day based on exploratory data). We deemed this delta to be clinically significant a priori. A sample of consecutive 81 weeks (567 days) was used. The period from June 8, 2011, to December 25, 2012, was chosen to correspond with the final welfare week payment release date of 2012.
Primary Measurements and Outcome
The total number of daily MHAs was compared between income assistance distribution days and nondistribution days. All apprehensions were included in weekly totals, including people apprehended more than once during the study period. Welfare week was defined as starting at midnight on the day the cheques were distributed and the subsequent 6 days following (that is, starting on Wednesday at 00:01 and finishing 24:00 the following Tuesday). A cutoff of 7 days was chosen to control for any day-to-day variability in MHA during weekends. Ethics approval was obtained from the University of British Columbia Research Ethics Board and the Research Division of the Vancouver Police Department.
Statistical Analysis
Data were analyzed using Excel, STATISTICA (StatSoft, Inc, Tulsa, OK), and PASS (NCSS, LLC, Kaysville, UT) software. MHAs were analyzed continuously, using the 2-tailed t test for independent means. Standard assumptions underlying the use of this approach were assessed—normality of distribution (coeffeicient of variation, Kolmogorov–Smirnov test) and homogeneity of variances (Levene’s test). The distributional assumptions underlying the use of the t test (normally distributed data and homogeneity of group variances) were found to be satisfied. www.LaRCP.ca
Figure 2 Mean Mental Health Assessments (MHAs) per week, with 95%
intervals by Police and Monthly Income Assistance (Welfare) Payments Association Between Mental Health Apprehensions
During the 567-day study period, there were 4009 MHAs (mean 7.1, range 1 to 18, MHAs per day). The number of MHAs per week during the 81 weeks is shown in Figure 1. The mean number of weekly apprehensions in the 19 weeks that followed income assistance distribution was 54.6 (95% CI 51.75 to 57.45). The mean number of weekly MHAs during the 62 weeks that did not directly follow income assistance payments was 48.6 (95% CI 46.35 to 50.85) (Figure 2). This difference was statistically significant (P = 0.004). The findings translate to an additional 85 MHA’s per year during the weeks welfare payments are disbursed. The number of mental health and substance-related presentations to the ED were also found to significantly increase the week following income assistance payments. There were 3477 mental health and substance-related presentations to the ED during 19 welfare payment weeks (mean 183/week; 95% CI 175.04 to 190.96) and 9545 presentations (mean 154/week; 95% CI 148.83 to 159.07) during the 62 nonpayment weeks. This translates to an 18.8% increase in mental health and substance-related presentations to the ED during the week following welfare disbursements (P < 0.001). Total number of ED visits remained stable and were not found to vary significantly between welfare payment and nonpayment weeks.
Discussion
Our results indicate a statistically significant increase in MHAs by police and an overall increase in mental health and substance-related presentations to the ED occurs in the 7 day period following income assistance payments, compared with other days of the month. These findings have potentially important implications for resource allocation by EDs, the police force, and within the community (for example, mental health outreach teams, drug and alcohol counselling services, and sobering units). Apprehended mental health patients seen in the ED are resource-intensive, typically requiring urgent assessment, direct supervision, pharmacologic and (or) physical restraint, seclusion, and treatment in a safe ED environment before being referred to psychiatry services or discharged. The nature and acuity of patients apprehended under the Mental Health Act and accompanied by police are not amenable to management in ED waiting rooms or rapid assessment zones, and necessitates formal evaluation and management in a designated care area. Increasingly, this is not available in the overcrowded and busy EDs in our region. Our study found an average of 1 extra MHA per day during welfare weeks, with a range of 1 to 18 MHAs per day; although not analyzed, the actual numbers appeared most pronounced, and at the high end of the range in the 4 days immediately following payments. The impact of highacuity patients on already crowded EDs has been shown to lengthen time to triage, assessment, treatment, and disposition for all patients.12 Additionally, MHA patients www.TheCJP.ca
Figure 2 Mean mental health apprehensions (MHAs) per week, with 95% CI 60
Mean MHAs per week, n
Results
50 40 30 20 10 0
Welfare Welfare
No welfare No welfare
[Layout: Please label the y axis: Mean MHAs per week, n]
requiring active intervention or who present an elopement risk may impact delivery of care to other patients by their resulting preferential placement onto ED stretchers. Our study has limitations that should be considered when interpreting our results. We examined only the actual number of MHAs by the Vancouver Police Department by date for a given period of time, and did not directly evaluate the relation of this to ED workload or flow. External factors (such as ED wait times for evaluation, changes to police staffing ratios, and other external circumstances, such as long weekends and community events) may have influenced some police decisions regarding whether to formally apprehend people under the Mental Health Act, although any such effects would be anticipated to be randomly distributed across the study period and analysis units. The Vancouver Police Department oversees policing of most of Vancouver, including the Downtown Eastside, Canada’s poorest demographic region, which includes a high concentration of inhabitants with mental illness and addictions. Thus our findings may not be generalizable to other settings. It is difficult to assess whether a sociological activity, such as monthly income assistance cheque distribution, is causally related to increased police or ED activity or simply an association in an already marginalized population. Previous research has indicated there is a link between lower socioeconomic status and both mental health and substance use disorders.13–16 Finally, the increase in MHAs following income assistance payments seen in our study may be related to other unknown confounders; however, our conclusions are supported by previous work, cited above, and consistent with impressions from clinicians at our institutions, suggesting that behaviour is influenced from the sudden increased ability to pursue excessive drug or alcohol intake a single, monthly payment provides. The additional analysis of presenting a complaint at the receiving hospitals during the study period showed that the number of patients with a primary triage complaint of mental health–related issues, substance abuse, or intoxication were also significantly increased during the week following welfare payments further supports the clinical relevance and importance of our findings. Increased ED presentations for The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 149
Original Research
mental health and substance-related complaints following welfare payments could not be fully attributed to increased MHAs by police during the same time period. EDs and community policing activities are, by their nature, both variable and largely unpredictable, which necessitates flexibility and adaptation to deliver optimum service. However, there is immense value in the ability to predict, wherever possible, surges in activity that can be planned for and addressed within health, police, and social policy realms. Since welfare cheque payments are determined by a provincial schedule and known in advance, the effect of predictable monthly increases in MHAs and substancerelated presentations to the ED could be potentially mitigated by adjusting ED resources during income assistance weeks (for example, extra psychiatry coverage, streamlined and expedited processing for patients accompanied by police, and enhanced ED capacity to place people apprehended under the Mental Health Act into appropriate areas of the department), modifying police staffing or ratios (for example, redistribution of patrols to areas with higher incidence of events and enhanced community–police mental health liaisons), augmenting and enhancing community resources (for example, increased capacity for self-referrals to detox and mental health services, and extended hours during welfare week), or changing the distribution of income assistance payments (for example, to a weekly, biweekly, or staggered model). It is possible that implementing some or all of the above changes could be beneficial with respect to enhanced service distribution to people apprehended under the Mental Health Act, particularly in large urban centres where resources are typically more diversified. Further, it is conceivable that changing the distribution of income assistance payments would have an overall smoothing or reducing effect on the impact of mental health and substance-related presentations to police, hospital, and community services during the course of the month rather than focused during specific weeks, and this possibility merits policy consideration and future investigation. Finally, there has been little research into the impact of mental health patients in crisis on citywide police services and how this influences ED workload and overcrowding. Further investigation as to the reciprocal implications of increasing numbers of mental health calls on police services would also be beneficial.
Conclusion
There is a statistically significant increase in the number of MHAs by police during the week following welfare payments. This is superimposed on a significant increase in overall mental health and substance-related complaints to the ED seen during the same period. This predictable pattern in mental health and substance-related presentations should be considered in ED psychiatry service coverage, police distribution and staffing models, and community resource planning. Moreover, changing the current British Columbia 150 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
model of income assistance payment release (for example, to a weekly system) could have a smoothing or reducing effect on MHAs during the course of each month, and this possibility merits policy consideration and future investigation.
Acknowledgements
We gratefully acknowledge the Vancouver Police Department for their essential support of this initiative; in particular, we thank Sargent Howard Tran and Constable Jimmy Nham. We also thank Dr Eric Grafstein, regional head of Emergency Medicine for the Vancouver Coastal Health Authority, for providing us data on overall mental health and substance– related ED presentations during the study period. No funding was provided for this research.
References
1. Li X, Sun H, Marsh DC, et al. Impact of welfare cheque issue days on a service for those intoxicated in public. Harm Reduct J. 2007;4:12–14. 2. Riddell C, Riddell R. Welfare checks, drug consumption, and health: evidence from Vancouver injection drug users. J Hum Resour. 2006;41(1):138–161. 3. Evans WN, Moore TJ. The short-term mortality consequences of income receipt. J Public Econ. 2011;95(11–12):1410–1424. 4. Verheul G, Singer SM, Christenson JM. Mortality and morbidity associated with the distribution of monthly welfare payments. Acad Emerg Med. 1997;4(2):118–123. 5. Brunette DD, Kominsky J, Ruiz E. Correlation of emergency health care use, 911 volume and jail activity with welfare check distribution. Ann Emerg Med. 1991;20(7):739–742. 6. Shaner A, Eckman TA, Roberts LJ, et al. Disability income, cocaine use and repeated hospitalization among schizophrenic cocaine abusers—a government sponsored revolving door? N Engl J Med. 1995;333:777–783. 7. Dobbkin C, Puller SL. The effects of government transfers on monthly cycles in drug abuse, hospitalization and mortality. J Public Econ. 2007;91(11–12):2137–2157. 8. Foley CF. Welfare payments and crime. Rev Econ Stat. 2011;93(1):97–112. 9. Wilson Bates F. Vancouver Police Department. Lost in transition: how a lack of capacity in the mental health system is failing Vancouver’s mentally ill and draining police resources [Internet]. Vancouver (BC): City of Vancouver; 2008 Feb [cited 2014 Jan 1]. Available from: http://vancouver.ca/police/as sets/pdf/ reports-policies/vpd-lost-in-transition.pdf. 10. Thompson S. Vancouver Police Department. Policing Vancouver’s mentally ill, the disturbing truth: beyond lost in transition [Internet]. Vancouver (BC): City of Vancouver; 2010 Sep [cited 2014 Jan 1]. Available from: http://vancouver.ca/police/assets/pdf/ reports-policies/vpd-lost-in-transition-part-2-draft.pdf. 11. Vancouver Police Department. Vancouver’s mental health crisis: an update report [Internet]. Vancouver (BC): City of Vancouver; 2013 Sep 13 [cited 2014 Jan 1]. Available from: http://vancouver.ca/ police/assets/pdf/reports-policies/mental-health-crisis.pdf. 12. McCarthy ML, Zeger SL, Ding R, et al. Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients. Ann Emerg Med. 2009;54(4):492–503.e4. 13. Frisman LK, Rosenheck R. The relationship of public support payments to substance abuse among homeless veterans with mental illness. Psychiatr Serv. 1997;48(60):792–795. 14. Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness, and incarceration. Public Health Rep. 2002;117(Suppl 1):S135–S145. 15. Fryers T, Melzer D, Jenkins R. Social inequalities and the common mental disorders: a systematic review of the evidence. Soc Psychiatry Psychiatr Epidemiol. 2003;38(5):229–237. 16. Pollack HA, Reuter P. Welfare receipt and substance-abuse treatment among low-income mothers: the impact of welfare reform. Am J Public Health. 2006;96(11):2024–2031. www.LaRCP.ca
Original Research
Association Between Mental Health Apprehensions by Police and Monthly Income Assistance (Welfare) Payments Tracy A Pickett, MD, BSc (MForensMed Candidate), FRCPC1; Robert J Stenstrom, MD, PhD, CCFP(EM)2; Riyad B Abu-Laban, MD, MHSc, DABEM, FRCPC3 Attending Physician, Emergency Department, St Paul’s Hospital, Vancouver, British Columbia; Clinical Associate Professor, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia; Graduate Student, Department of Forensic Medicine, Monash University, Melbourne, Australia. Correspondence: Emergency Department, St Paul’s Hospital, 1081 Burrard Street, Vancouver, BC V6Z 1Y6; [email protected].
1
Attending Physician and Research Director, Emergency Department, St Paul’s Hospital, Vancouver, British Columbia; Assistant Professor, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia.
2
3
Attending Physician, Emergency Department, Vancouver General Hospital, Vancouver, British Columbia; Associate Professor and Research Director, Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia.
Key Words: mental health apprehension, police, welfare, income assistance payment, emergency department, temporal trends, time series Received March 2014, revised, and accepted September 2014. This study was presented in abstract form in an oral presentation at the Canadian Association of Emergency Physicians Conference, Ottawa, Ontario, June 1, 2014.
Objective: Social misconduct, increased police activity, and increased emergency department (ED) use are associated with monthly income assistance (welfare) payments. The relation, if any, between welfare payments and mental health and addictions presentations to the ED requiring police involvement remains unknown. Our purpose was to determine if a relation exists between mental health apprehensions (MHAs) by police and monthly welfare cheque distribution, and the association between monthly payments and mental health and substance-related ED presentations. Method: The Vancouver Police administrative database was analyzed during an 81-week period (June 8, 2011, to December 25, 2012). Comparisons were made between the numbers of MHAs by police during the week following welfare payment to those during nonpayment weeks. The weekly number of mental health and substance-related ED presentations were also analyzed during the study period. MHAs were analyzed continuously, and compared using the 2-tailed t test. Results: During the study period, 4009 MHAs occurred (range 1 to 18 MHAs/day). The mean weekly MHAs during welfare week was 54.6 (95% CI 51.75 to 57.45), compared with 48.6 (95% CI 46.35 to 50.85) during nonpayment weeks (P = 0.004). This translates to 85 MHAs annually related to welfare payments. Total mental health and addictions-related presentations to the ED were also significantly increased in the week following welfare payments (P < 0.001), and could not be solely attributed to increased MHAs by police. Conclusion: A statistically significant increase in the number of MHAs by police follows welfare payments. This is superimposed on a significant increase in overall mental health and substance-related ED presentations seen during the same period. WWW
Association entre les arrestations pour santé mentale faites par la police et le revenu mensuel des prestations d’aide sociale (bien-être) Objectif : L’inconduite sociale, l’intervention accrue de la police, et l’utilisation en hausse des services d’urgence (SU) sont associées au revenu mensuel des prestations d’aide sociale (bien-être). La relation, si elle existe, entre les prestations d’aide sociale, la santé mentale, et les visites au SU pour toxicomanies qui demandent l’intervention de la police demeure inconnue. Notre objectif était de déterminer s’il existe une relation entre les arrestations pour santé mentale (ASM) faites par la police et la distribution mensuelle des chèques de bien-être, et l’association entre les prestations mensuelles et la santé mentale et les visites au SU liées à des substances. Méthode : La base de données administrative de la police de Vancouver a été analysée durant 81 semaines (du 8 juin 2011 au 25 décembre 2012). Des comparaisons ont été établies entre le nombre d’ASM faites par la police durant la semaine suivant les prestations d’aide sociale et celles faites durant les semaines sans prestations. Le nombre hebdomadaire de visites au SU liées à la santé mentale et aux substances a aussi été analysé durant la période de l’étude. Les ASM ont été analysées en continu, et comparées à l’aide du test t bilatéral. 146 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
www.LaRCP.ca
Association Between Mental Health Apprehensions by Police and Monthly Income Assistance (Welfare) Payments
Résultats : Durant la période de l’étude, il y a eu 4009 ASM (de 1 à 18 ASM par jour). La moyenne hebdomadaire des ASM durant la semaine des prestations d’aide sociale était de 54,6 (IC à 95 % 51,75 à 57,45), comparativement à 48,6 (IC à 95 % 46,35 à 50,85) durant les semaines sans prestations (P = 0,004). Ce qui signifie que 85 ASM sont reliées annuellement aux prestations d’aide sociale. Le total des visites au SU liées à la santé mentale et aux toxicomanies augmentait aussi significativement dans la semaine suivant les prestations d’aide sociale (P < 0,001), et ne pouvait pas être attribué uniquement à l’augmentation des ASM faites par la police. Conclusion : Une augmentation statistiquement significative du nombre d’ASM faites par la police suit les prestations d’aide sociale. Elle se superpose à une augmentation significative des visites au SU liées à la santé mentale et aux substances durant la même période.
I
ncome assistance, also known as welfare, is a financial safety net that exists in Canada for eligible people who have limited ability to earn income because of personal circumstances or disability, including mental health issues. Income assistance provides regular payments based on financial need, released once monthly in most provinces as per a predetermined, provincially administered schedule. Monthly lump-sum welfare payments have been associated with increased morbidity, mortality, and crime in both Canada and the United States.1–8 During the past decade, ED overcrowding, deinstitutionalization of mental health patients, and increasingly easy access to drugs of abuse have stretched health care and community resources such that police must increasingly function as de facto front-line mental health workers.9,10 The questions of whether monthly welfare cheque distribution affects police interactions with mental health patients, and any impact this has on ED activity, has previously not been addressed. In Vancouver, about one-third of all calls to police are related to mental health issues.11 Six to 8 per cent of these calls result in apprehension of an individual by Police under Section 28 of the British Columbia Mental Health Act; a legislation that authorizes police to apprehend and transport an individual to a physician for assessment (usually in the ED) if that person appears to have a mental disorder and is acting in a manner with the potential to endanger their safety or the safety of others. Common reasons for apprehension under Section 28 include psychosis, suicidal attempt or ideation, intoxication with drugs or alcohol, and behavioural issues. A Section 28 MHA is often a last resort when police have exhausted other means of resolving a situation. The impact of monthly income assistance payments on the number of MHAs by police has not been studied in Canada or elsewhere. Our objective was to determine if a relation exists between the number of MHAs by police in Vancouver and monthly welfare cheque distribution. We hypothesized that
Clinical Implications •
Predictable and consistent increases in MHAs by police and mental health and substance-related presentations to the ED following monthly welfare payments should be considered in ED staffing, police distribution models, and community resource planning.
•
Changing the model of monthly welfare payments (for example, to a weekly system) could have a smoothing effect on MHAs in the course of each month, and this possibility merits policy consideration and future investigation.
Limitations •
Vancouver is a busy urban centre, with some core regions of the city having a high concentration of inhabitants with mental illness and addictions. Our findings may not be generalizable to other regions.
•
The impact of MHAs were not correlated to ED or police workload or flow.
•
The increase in MHAs following income assistance payments may be related to other unknown and undetermined confounders. It is difficult to assess whether a sociological activity, such as welfare cheque distribution, is causally related to increased police or ED activity, or simply an association in an already marginalized population.
there would be more MHAs in the days on or immediately following welfare cheque payments. Additionally, for secondary purposes, we assessed the number of overall mental health and substance-related presentations to the ED during the study period. We hypothesized that there would also be increased mental health and substance-related ED presentations in the week following welfare payments, but this would not be fully accounted for by increased MHAs by police. If such an association exists, our findings could potentially influence ED and (or) police staffing models, ED surge capacity planning, community resources, and even public and social policies regarding payment approaches.
Methods Abbreviations ED
emergency department
MHA
mental health apprehension
PRIME
Police Records Information Management Environment
www.TheCJP.ca
Study Design and Population
The study took place in Vancouver, a Canadian urban centre with a population of about 800 000 people. We undertook an administrative database investigation of MHAs by the Vancouver Police Department during an The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 147
Figure Weekly (Wednesday to Tuesday) total Mental Health Apprehensions (MHAs) by Vancouver police Original1 Research Figure 1 Weekly (Wednesday to Tuesday) total mental health apprehensions (MHAs) by Vancouver police
80 70 60
Total MHAs, n
50 40 30 20 10 0
Week of study
Welfare payment weeks
Nonwelfare payment weeks
Welfare payment weeks
81-week (567-day) period between June 8, 2011, and Non-welfare payment weeks December 25, 2012. The Vancouver Police Department is a municipal police force with jurisdiction over the City of Vancouver, excluding the University of British Columbia and University Endowment Lands. The study population consisted of all people apprehended by Vancouver Police under Section 28 of the British Columbia Mental Health Act during the study period, as captured through the Vancouver Police Department PRIME database. PRIME is a real-time computer database that records all Vancouver Police Department dispatches and encounters. Variables captured included absolute number of people formally apprehended under Section 28 of the British Columbia Mental Health Act and the date of apprehension. Personal identifiers including name, age, sex, circumstances surrounding the apprehension, prior MHAs, medical diagnosis, or whether an individual received income assistance payments were not collected. People with a police encounter who were otherwise managed without apprehension under Section 28 of the British Columbia Mental Health Act were excluded. The overall number of mental health and substance-related presentations (including police MHAs) to the 2 study hospitals was extracted from the Vancouver Coastal Health Authority regional ED dataset, which holds comprehensive data on all ED encounters at the study hospitals. Data linkage to establish whether patients were receiving welfare payments was not performed.
Sample Size and Selection
We assumed that the number of MHAs per day would be normally distributed. We categorized the daily numbers of MHAs by police into the 1-week (7-day) period following welfare payment (welfare cheque days) or nonpayment weeks (nonwelfare cheque days). Based on about a 3-to-1 ratio of nonwelfare cheque days to welfare cheque days, we 148 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
determined that 510 days (total) were required to have 90% power to detect a 1-call per day mean difference (standard deviation of 3 calls per day based on exploratory data). We deemed this delta to be clinically significant a priori. A sample of consecutive 81 weeks (567 days) was used. The period from June 8, 2011, to December 25, 2012, was chosen to correspond with the final welfare week payment release date of 2012.
Primary Measurements and Outcome
The total number of daily MHAs was compared between income assistance distribution days and nondistribution days. All apprehensions were included in weekly totals, including people apprehended more than once during the study period. Welfare week was defined as starting at midnight on the day the cheques were distributed and the subsequent 6 days following (that is, starting on Wednesday at 00:01 and finishing 24:00 the following Tuesday). A cutoff of 7 days was chosen to control for any day-to-day variability in MHA during weekends. Ethics approval was obtained from the University of British Columbia Research Ethics Board and the Research Division of the Vancouver Police Department.
Statistical Analysis
Data were analyzed using Excel, STATISTICA (StatSoft, Inc, Tulsa, OK), and PASS (NCSS, LLC, Kaysville, UT) software. MHAs were analyzed continuously, using the 2-tailed t test for independent means. Standard assumptions underlying the use of this approach were assessed—normality of distribution (coeffeicient of variation, Kolmogorov–Smirnov test) and homogeneity of variances (Levene’s test). The distributional assumptions underlying the use of the t test (normally distributed data and homogeneity of group variances) were found to be satisfied. www.LaRCP.ca
Figure 2 Mean Mental Health Assessments (MHAs) per week, with 95%
intervals by Police and Monthly Income Assistance (Welfare) Payments Association Between Mental Health Apprehensions
During the 567-day study period, there were 4009 MHAs (mean 7.1, range 1 to 18, MHAs per day). The number of MHAs per week during the 81 weeks is shown in Figure 1. The mean number of weekly apprehensions in the 19 weeks that followed income assistance distribution was 54.6 (95% CI 51.75 to 57.45). The mean number of weekly MHAs during the 62 weeks that did not directly follow income assistance payments was 48.6 (95% CI 46.35 to 50.85) (Figure 2). This difference was statistically significant (P = 0.004). The findings translate to an additional 85 MHA’s per year during the weeks welfare payments are disbursed. The number of mental health and substance-related presentations to the ED were also found to significantly increase the week following income assistance payments. There were 3477 mental health and substance-related presentations to the ED during 19 welfare payment weeks (mean 183/week; 95% CI 175.04 to 190.96) and 9545 presentations (mean 154/week; 95% CI 148.83 to 159.07) during the 62 nonpayment weeks. This translates to an 18.8% increase in mental health and substance-related presentations to the ED during the week following welfare disbursements (P < 0.001). Total number of ED visits remained stable and were not found to vary significantly between welfare payment and nonpayment weeks.
Discussion
Our results indicate a statistically significant increase in MHAs by police and an overall increase in mental health and substance-related presentations to the ED occurs in the 7 day period following income assistance payments, compared with other days of the month. These findings have potentially important implications for resource allocation by EDs, the police force, and within the community (for example, mental health outreach teams, drug and alcohol counselling services, and sobering units). Apprehended mental health patients seen in the ED are resource-intensive, typically requiring urgent assessment, direct supervision, pharmacologic and (or) physical restraint, seclusion, and treatment in a safe ED environment before being referred to psychiatry services or discharged. The nature and acuity of patients apprehended under the Mental Health Act and accompanied by police are not amenable to management in ED waiting rooms or rapid assessment zones, and necessitates formal evaluation and management in a designated care area. Increasingly, this is not available in the overcrowded and busy EDs in our region. Our study found an average of 1 extra MHA per day during welfare weeks, with a range of 1 to 18 MHAs per day; although not analyzed, the actual numbers appeared most pronounced, and at the high end of the range in the 4 days immediately following payments. The impact of highacuity patients on already crowded EDs has been shown to lengthen time to triage, assessment, treatment, and disposition for all patients.12 Additionally, MHA patients www.TheCJP.ca
Figure 2 Mean mental health apprehensions (MHAs) per week, with 95% CI 60
Mean MHAs per week, n
Results
50 40 30 20 10 0
Welfare Welfare
No welfare No welfare
[Layout: Please label the y axis: Mean MHAs per week, n]
requiring active intervention or who present an elopement risk may impact delivery of care to other patients by their resulting preferential placement onto ED stretchers. Our study has limitations that should be considered when interpreting our results. We examined only the actual number of MHAs by the Vancouver Police Department by date for a given period of time, and did not directly evaluate the relation of this to ED workload or flow. External factors (such as ED wait times for evaluation, changes to police staffing ratios, and other external circumstances, such as long weekends and community events) may have influenced some police decisions regarding whether to formally apprehend people under the Mental Health Act, although any such effects would be anticipated to be randomly distributed across the study period and analysis units. The Vancouver Police Department oversees policing of most of Vancouver, including the Downtown Eastside, Canada’s poorest demographic region, which includes a high concentration of inhabitants with mental illness and addictions. Thus our findings may not be generalizable to other settings. It is difficult to assess whether a sociological activity, such as monthly income assistance cheque distribution, is causally related to increased police or ED activity or simply an association in an already marginalized population. Previous research has indicated there is a link between lower socioeconomic status and both mental health and substance use disorders.13–16 Finally, the increase in MHAs following income assistance payments seen in our study may be related to other unknown confounders; however, our conclusions are supported by previous work, cited above, and consistent with impressions from clinicians at our institutions, suggesting that behaviour is influenced from the sudden increased ability to pursue excessive drug or alcohol intake a single, monthly payment provides. The additional analysis of presenting a complaint at the receiving hospitals during the study period showed that the number of patients with a primary triage complaint of mental health–related issues, substance abuse, or intoxication were also significantly increased during the week following welfare payments further supports the clinical relevance and importance of our findings. Increased ED presentations for The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 149
Original Research
mental health and substance-related complaints following welfare payments could not be fully attributed to increased MHAs by police during the same time period. EDs and community policing activities are, by their nature, both variable and largely unpredictable, which necessitates flexibility and adaptation to deliver optimum service. However, there is immense value in the ability to predict, wherever possible, surges in activity that can be planned for and addressed within health, police, and social policy realms. Since welfare cheque payments are determined by a provincial schedule and known in advance, the effect of predictable monthly increases in MHAs and substancerelated presentations to the ED could be potentially mitigated by adjusting ED resources during income assistance weeks (for example, extra psychiatry coverage, streamlined and expedited processing for patients accompanied by police, and enhanced ED capacity to place people apprehended under the Mental Health Act into appropriate areas of the department), modifying police staffing or ratios (for example, redistribution of patrols to areas with higher incidence of events and enhanced community–police mental health liaisons), augmenting and enhancing community resources (for example, increased capacity for self-referrals to detox and mental health services, and extended hours during welfare week), or changing the distribution of income assistance payments (for example, to a weekly, biweekly, or staggered model). It is possible that implementing some or all of the above changes could be beneficial with respect to enhanced service distribution to people apprehended under the Mental Health Act, particularly in large urban centres where resources are typically more diversified. Further, it is conceivable that changing the distribution of income assistance payments would have an overall smoothing or reducing effect on the impact of mental health and substance-related presentations to police, hospital, and community services during the course of the month rather than focused during specific weeks, and this possibility merits policy consideration and future investigation. Finally, there has been little research into the impact of mental health patients in crisis on citywide police services and how this influences ED workload and overcrowding. Further investigation as to the reciprocal implications of increasing numbers of mental health calls on police services would also be beneficial.
Conclusion
There is a statistically significant increase in the number of MHAs by police during the week following welfare payments. This is superimposed on a significant increase in overall mental health and substance-related complaints to the ED seen during the same period. This predictable pattern in mental health and substance-related presentations should be considered in ED psychiatry service coverage, police distribution and staffing models, and community resource planning. Moreover, changing the current British Columbia 150 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015
model of income assistance payment release (for example, to a weekly system) could have a smoothing or reducing effect on MHAs during the course of each month, and this possibility merits policy consideration and future investigation.
Acknowledgements
We gratefully acknowledge the Vancouver Police Department for their essential support of this initiative; in particular, we thank Sargent Howard Tran and Constable Jimmy Nham. We also thank Dr Eric Grafstein, regional head of Emergency Medicine for the Vancouver Coastal Health Authority, for providing us data on overall mental health and substance– related ED presentations during the study period. No funding was provided for this research.
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